Download Burn Clinical Practice Guideline

Burn Clinical
Practice
Guideline
Developed by
Texas EMS Trauma & Acute
Care Foundation Trauma Division
3400 Enfield Road
Austin, TX 78703
Phone: 512.524.2892
www.tetaf.org
Burn Clinical Practice Guideline
Developed by
Texas EMS Trauma & Acute Care Foundation Trauma Division
Content
The content for this publication was developed by the TETAF Trauma Division, led by Rose Marie Bolenbaucher,
M.S.N., RN, TCRN, through collaboration with Texas Trauma Program Managers and Texas Burn Center program
leadership to provide guidance to hospitals in Texas. The content was reviewed and edited by Dr. Brian
Eastridge and the GETAC Trauma Systems Committee Trauma Medical Directors Workgroup. This document
is intended to be used as guidance only in the development of burn treatment policies and protocols within
hospitals in Texas. This is a living document that will be reviewed annually and updated as needed to maintain
the standards of care set by national evidence-based findings.
Edited by
Brian Eastridge, M.D., Trauma Medical Director and Trauma/Acute-Care Surgeon at University Hospital
in San Antonio
Contributors
Rose Bolenbaucher, M.S.N., RN, TCRN, Trauma Program Education, Trauma Services, University Health System, San Antonio
Tracy Cotner-Pouncy, RN, Senior Director, Trauma Services, University Health System, San Antonio
Courtney Edwards, M.S.N./M.P.H., RN, Injury Prevention Manager, Parkland Health & Hospital System, Dallas
Bonnie Jackson, RN, M.S.N., CCNS, Burn Program Manager, U.S. Army Burn Center, U.S. Army Institute of Surgical Research, San Antonio Military Medical Center, Fort Sam Houston, Texas
Wendy McNabb, RN, Director, Trauma and Burn Services, University Medical Center, Lubbock
Col. Elizabeth A. Mann-Salinas, Ph.D., RN, FCCM, Task Area Manager, Systems of Care for Complex Patients, U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas
Jenny Oliver, B.S.N., RN, Assistant Director of Trauma Services, University Health System, San Antonio
Brenda Putz, RN, B.S.N., Director, Texas EMS
Trauma & Acute Care Foundation
Kathy Rodgers, RN, M.S.N., CNS, TCRN, CCRN, CEN, Trauma Services Director, CHRISTUS St. Elizabeth Hospital, Beaumont
Sue Vanek, B.S., M.B.A., RN, former Burn Program Manager, Parkland Regional Burn Center, Parkland Health and Hospital System, Dallas
Brenda Putz, RN, B.S.N., TETAF, Austin
Governor’s EMS and Trauma Advisory Council
Trauma Systems Committee Trauma Medical
Directors Workgroup
Ann Ward, APR, A.Ward Strategic Communications
Design by
Barbara Battista, Graphic Design Services
Photo Credits
Photographs in this publication are courtesy of
University Medical Center, Lubbock.
Copyright © May 2016 by the Texas EMS
Trauma & Acute Care Foundation. Individuals
may download and print this publication for
use within their organization. Other uses –
including mass copying and distribution of
the copyright publication – are prohibited.
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Contents
Burn Clinical Practice Guideline
Treatment Protocol Considerations................................................................................................ 4
Advanced Trauma Life Support Process/Assessment.............................................................. 5
Airway with C-Spine Protection............................................................................................. 5
Breathing........................................................................................................................................ 5
Circulation...................................................................................................................................... 5
Disability......................................................................................................................................... 5
Exposure......................................................................................................................................... 5
Fluid Resuscitation................................................................................................................................ 5
Determination of Total Body Surface Area......................................................................... 5
Burn Classification....................................................................................................................... 6
Burn History................................................................................................................................... 6
Diagnostics/Basic Laboratory Tests....................................................................................... 6
Special Circumstances......................................................................................................................... 7
Pediatric Considerations........................................................................................................... 8
Geriatric Considerations........................................................................................................... 9
Electrical Injury Considerations.............................................................................................. 9
Chemical Injury Considerations............................................................................................. 9
Circumferential Burns Considerations................................................................................. 9
Additional Considerations for All Types of Burn Patients...........................................10
Wound Care...........................................................................................................................................10
Pain and Anxiety Management............................................................................................10
Burn Center Referral Criteria............................................................................................................11
Psychosocial and Spiritual Support..............................................................................................11
Examples of Fluid Resuscitation and Wound Care Protocols.......................................12
Forms and Tools for Documentation...........................................................................................14
Education Recommendations.........................................................................................................15
Appendices.................................................................................................................................................16
Rule of Nines.........................................................................................................................................17
24-Hour Burn Care Sheet..................................................................................................................18
References...................................................................................................................................................20
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Burn Clinical Practice Guideline
Treatment of burns is not always straightforward. National
and international guidelines differ from one region to
another. However, all sources agree that managing burn
cases in the first 24 hours is critical and directly correlates
to morbidity and mortality.
3. Address guidelines systematically and include:
a) ABCDE as in all types of trauma cases,
b) Fluid resuscitation,
c) Wound care,
d) Pain management,
e) Transfer guidelines, and
f ) Psychosocial and spiritual support.
To deliver optimal patient care to burn victims, health
care providers must understand the pathophysiology of
burn injuries, their classification, the appropriate use of
various types of surgical treatment and the latest updates
in burn science. Some patients may be treated effectively
in the hospital emergency department while others may
require hospitalization or stabilization/transfer to a burn
center as quickly as possible.
Treatment Protocol Considerations
All trauma cases – including patients with burn
injuries – should be treated by initially following
the guidelines for Advanced Trauma Life Support to
ensure that life-threatening injuries are addressed
immediately. ABCDs first! The appropriate assessment
and management of burn patients in the first hours
following injury have resulted in the 96 percent national
survival rate for patients transferred to a verified burn
center in 2011, as reported by Advanced Burn Life
Support.
The clinical situation for treating burn cases needs
clear guidelines to cover all aspects of care during the
treatment process. Through a collaboration of Texas
verified burn centers and the Texas EMS Trauma & Acute
Care Foundation (TETAF), this publication was created
to provide clinical practice guidelines for hospitals in
Texas for assessing, classifying and treating the patient
experiencing a burn injury. Utilization of these guidelines
provides the framework to develop burn care policies in
Texas hospitals and ensure consistent, appropriate care
for burn patients across the state.
This publication provides information and guidance
in developing policies for treating burn patients.
Information is presented in the order in which
assessment/care should be provided. After addressing
the ABCDs of life support, focus turns to burn injuries.
Replacing fluid lost from the burns is critical, and an
accurate assessment of the severity and extent of
the burns is needed to calculate the amount of fluid
to provide. Wound care and pain management are
addressed next. Many of these activities are occurring
almost simultaneously, especially if the extent of the
burn injuries indicates transfer to a burn center is
needed. Psychosocial and spiritual support may be
provided throughout the assessment, treatment and
stabilization processes.
Publication Objectives
TETAF’s goals with this publication include the following:
1. Provide resources and references for burn care in Texas
based on nationally accepted standards of care.
2. Provide guidelines and assistance for the development
of policies and ensure consistent practice across Texas for
all burn patients.
4
Advanced Trauma Life Support
Process/Assessment
Assess perfusion status by the following techniques:
a. Pulse check,
b. Capillary refill, and
c. Urinary output (see additional parameters in
the section Determination of Total Body Surface Area,
below and on page 6).
Airway with C-Spine Protection
As in all trauma cases, early recognition of airway
compromise followed by prompt intervention to ensure
airway maintenance should be completed. If there is soot
in the mouth, consider early intubation even if the patient
is breathing normally. Follow ATLS guidelines and ensure
the patient has a definitive airway established and continue
assessments to monitor ventilation. Assessment of the
airway includes:
a. Removing any burning agent, including chemicals.
b. Inspecting for singed nasal, facial and eyebrow hairs.
c. Looking for burns and edema around the head and neck.
d. Determining if there are circumferential burns to
the chest which may inhibit ventilation and require
escharotomy.
Disability
Detect if there are any manifestations of neurological
deficits.
Exposure
Evidence-based research supports total exposure of
the patient to assess the severity of burns and initiate
treatment.
a. Remove any burning agent, including chemicals.
b. Work toward maintaining a normal temperature by
removing wet dressings and covering with dry, sterile
dressings.
c. Begin re-warming the patient with blankets and
warmed fluid. Ambient temperature should be from
28° to 32°C (82° to 90°F). The patient’s core temperature
must be kept at least above 34°C. Increase the room
temperature if necessary.
d. Remove all jewelry.
Breathing
Determine if the patient is moving air or not. Follow ATLS
guidelines. Assessment of breathing includes:
a. Auscultating breath sounds,
b. Monitoring rate, depth and work of breathing, and
c. Monitoring for dyspnea and stridor.
Fluid Resuscitation
Circulation
Monitor circulation and cardiac status with hemorrhage
control. Obtain appropriate vascular access and use a
device to monitor heart rate and blood pressure. Cannulate
two veins with large caliber intravenous catheters and
initiate warmed fluids. Avoid burned areas when possible.
In large burns where the IV has been placed through
burned skin, the IVs should be sutured. Insert intravenous
catheters to initiate intraosseous infusion when unable to
obtain vascular access. (Note: Fluid resuscitation continues
in the next column and recommendations by specific burn
centers are discussed on pages 12 and 13.)
Fluid resuscitation is a mainstay in the treatment of burn
patients. The guidelines of Advanced Trauma Life Support
should be followed to maintain perfusion. Verified burn
centers in different areas of Texas follow different guidelines
with respect to fluid resuscitation though the underlying
principle of maintaining end organ perfusion are the same.
Determination of Total Body Surface Area
The severity of a burn injury is determined by the total
body surface area burned and the depth of the burn. Total
body surface area (TBSA) is an assessed measure of the
severity of skin burns. In adults, the “Rule of Nines” is used
to determine the total percentage of the burned area for
each major section of the body. However, this rule cannot
be used in pediatric burns.
Ongoing fluid requirements are adjusted based on the
individual patient’s response to the resuscitation as
evidenced by urinary output in addition to hemodynamic
parameters.
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The Lund-Browder chart is one of the most accurate
methods to estimate not only the size of the burn area
but also the burn degree in both adult and pediatric burn
patients. This chart is widely used in clinical practice. The
Lund-Browder chart is available in many burn centers and
on the Internet; see the Education Recommendations on
page 15 of this publication for more information.
An accurate determination of the size of the burned areas
is essential to estimate the amount of intravenous fluids
required and the appropriateness of transfer to a burn
unit. The degree of burns also is calculated to estimate the
prognosis as well as the type of treatment.
infant
Percentage of Total Body Surface Area
Clinicians should determine the total body surface area
affected by the burn by using the formula derived from
the Rule of Nines, the Berkow formula or the Lund-Browder
chart. The rule of palms can be used to measure the extent
of small or scattered burns. The patient’s hand (including
fingers) is equal to 1 percent of TBSA.
Anterior
Palmar
Method
Patient’s palm,
including fingers.
Burn Classification or Severity
A visual assessment should be made to determine the
severity of the burn injuries. The thickness of the burn –
how many layers of skin as well as the amount of other
tissue damaged – is used to classify the degree of the burn.
The classification levels of burns include the following
degrees:
Note: The American Burn Association recently has approved the Rule of
10, and once it is implemented, will be incorporated in this document.
n n n n n Posterior
First degree burns – Redness and pain of the affected
skin. Minor epithelial damage occurs without formation
of blisters. Typically occurs with sunburns.
Superficial second degree burns (superficial partial
thickness burns) – Complete epithelial damage and
only papillary dermal damage occurs. This degree leaves
no neurovascular damage. It causes pain, bleeds and
presents with blisters. Epithelial repair occurs within
14 days, and mostly leaves no scars after healing.
Sometimes discoloration remains.
Deep second degree burns (deep partial thickness
burns) – Complete epithelial damage and damage of
the reticular dermis are present. Blisters also can be
present but are bigger than in superficial second degree
burns. Healing can occur but takes longer than 14 days.
Third degree burns (full thickness burns) – The epidermis,
dermis and subcutaneous tissue are involved. The skin
appears white and/or leathery with thrombosed vessels.
Fourth degree burns – This classification may be used
when a burn involves the underlying fascia, muscles and
even bones.
Brief Categorization of Burns
Full thickness burns are more severe than those that damage
only partial layers of skin. For purposes of determining the
percentage of total body surface area burned, only partial
and full thickness burns are used. Correlating with the degree
classification are these categories of burns by thickness of
damage:
n Superficial burn injury (first degree);
n Superficial partial-thickness burns (superficial second
degree);
n Deep partial-thickness burns (deep second degree);
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n n Full-thickness burns (third degree); and
Full-thickness burns involving the underlying fascia,
muscles and bones (fourth degree).
Burn History
Once the ABCDs are completed and fluid resuscitation
has been initiated, attention should be focused on
obtaining information about how the burn injury
occurred. This burn history should include:
n
The patient’s or EMS provider’s history of the events,
n
Time of injury,
n Where the injury occurred including if the patient
was in an enclosed space,
n If there was loss of consciousness,
n Causative agent/mechanism of burn,
n How long the patient was exposed to the burn
source,
n If decontamination occurred,
n Suspicion of abuse or intentional injury,
n Possibility of carbon monoxide intoxication based
on the history of burns in a closed area as well as the
presence of soot in the mouth and nose,
n Presence of facial burns, if applicable,
n Examination of the cornea,
n Consistency of burn with the history provided,
n Allergies and usual medications,
n Past medical history including the date of the last
tetanus shot, and
n The patient’s weight.
First Degree Burn
n n Urine drug test, and
Human chorionic gonadotropin (B-HCG) if the patient
is female.
Consider Special Circumstances
Diagnostics/Basic Laboratory Tests
Basic laboratory tests may include but are not limited
to the following:
n Complete blood count (CBC) and arterial blood gas
(ABG) analysis,
n Urea and electrolytes (U&E), also known as basic
metabolic profile,
n Prothrombin time (PT) / Partial thrombin time (PTT)
and International Normalized Ration (INR) should be
considered if the patient is on anticoagulants,
n Blood glucose level,
Patient characteristics as well as the cause of the burn
injury may require special considerations in the assessment
as well as the treatment of the patient. Age of the burn
patient should be taken into account in assessments and
treatments. For example, children may be the victims of
abuse, and elderly burn patients need to be managed
aggressively due to their overall health conditions and
co-morbidities. Specific types of burn injuries – such
as electrical and chemical burns – also require special
interventions.
7
Pediatric Considerations
If the patient is a child, look for signs of abuse.
Specific things to consider include the following:
n Is the pattern of burn consistent with the story?
n Does the story change?
n Observe the caregiver’s behavior and be
suspicious if the individual seems disinterested
in the child’s care.
n Observe interactions – if possible – between
the child and caregiver; strange behavior may
indicate an unhealthy relationship.
n Scald burns with circumferential demarcation
line often indicate an intentional action.
n Accidental burns usually have splatter marks
and inconsistent edges.
Non-Accidental Burn
Additional Pediatric Considerations
Burn-related injuries are a leading cause of morbidity
and mortality in children and rank third in children age
1 - 9 years. Appreciating the major differences between
burn management in children and adults is important.
With nearly three times the body surface area (BSA) to
body mass ratio of adults, fluid losses are proportionately
higher in children than adults and predispose the child to
hypothermia which must be aggressively avoided. Be sure
to address appropriate fluid resuscitation, hypothermia,
pain control and blood glucose level.
n n n n Accidental Burn
8
Fluid resuscitation in a child must be more precise.
Urinary output is the most sensitive indicator of fluid
resuscitation.
Hypothermia is a continued high risk in this patient
population due to the high surface-to-volume ratio and
low-fat mass. Hypothermia can increase the depth of
the burn.
Monitor the pediatric patient’s blood glucose level.
In this patient population, temperature regulation is
partially based on non-shivering thermogenesis, which
further increases metabolic rate.
Thrashing, resisting care and dislodging important
treatment adjuncts such as catheters, endotracheal
tubes, etc., may indicate pain in children who are not
able to express pain. Begin with small doses, 0.1 mg/kg
of morphine intravenously initially and increase as long
as patient remains hemodynamically stable and shows
no evidence of respiratory depression.
Geriatric Considerations
Advances in medical care and longevity have resulted in
an increase in the elderly population, and burn injuries in
this subset of the population are becoming more prevalent.
With patients 65 years of age and older, the risk of mortality
is increased, so early and aggressive management of
burns are needed. Thinner skin, poorer circulation, preexisting conditions, fewer reserves and higher complication
rates increase morbidity and mortality. Because of age,
thoughtful consideration should be given to treatment,
such as:
n Early surgical intervention is recommended.
n Use care in fluid resuscitation so as not to cause fluid
overload. Be aware that it may require more fluid to
resuscitate the same burn size than expected to avoid
hypovolemia, possibly due to the decreased skin turgor.
n Implement aggressive respiratory therapy. Inhalation
injury tends to be more prevalent in elderly patients
because they are generally less mobile. Inhalation
injury is a significant predictor of mortality and is an
important comorbidity factor.
n Transfer to a burn center is recommended.
n For optimum outcomes, aggressive rehabilitation
is needed.
Chemical Injury Considerations
All ERs are required to maintain a reference manual that
is updated regularly with chemicals used in their region.
Every chemical and the appropriate care for an exposure
should be included in the Material Safety Data Sheet
(MSDS). This reference should define the appropriate type
of emergency care for each chemical in the region that
could cause a burn.
With chemical burns, it is important to determine that the
patient has undergone decontamination for an appropriate
length of time based on the specific recommendations in
the MSDS, at least 20 minutes or until the burning process
has stopped. If the burn was caused by a chemical agent,
providers should take appropriate precautions to protect
themselves and the immediate environment from exposure
to the chemical agent.
Circumferential Burns Considerations
Burns that encircle an extremity, the chest or the abdomen
require special attention. Edema and swelling in the tissue
under the burn may cause the burnt skin – which is rigid –
to act like a tourniquet. In a limb, this can cause ischemia.
In the chest or abdomen, it can restrict chest expansion
and diaphragm movement and interfere with ventilation.
A burn center surgeon should be consulted prior to
treatment.
Electrical Injury Considerations
When the patient’s burns were caused by an electrical
injury, circumstances dictate special care consideration,
including the following:
n Assess cardiac rhythm as life-threatening arrhythmias
may be present.
n Assess contact points (it is possible to have more than
two).
n Be aware that significant underlying tissue and muscle
injury may be present in electrical injuries. If this
happens, muscle fibers and chemicals may be released
into the bloodstream, causing electrolyte disturbances.
n Assess for myobloginuria; the presence of these
muscles fragments in the urine can cause electrolyte
disturbances and kidney failure.
Among the interventions that typically may be
implemented are the following:
n Checking for pulses; often a doppler scan is needed.
n Elevating extremities if not contraindicated.
n Performing an escharotomy – full thickness incision
of the burn down to the subcutaneous fat, to release
constricting unyielding burned skin. This may be
necessary to restore blood flow. However, this optimally
should be performed after appropriate consultation
with the burn center surgeon.
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Additional Considerations for All Types of Burn Patients
Regardless of the patient’s age or type of burn, these
treatment considerations apply to all burn patients.
n Insert a gastric tube as directed by a physician.
n Monitor urinary output to assess fluid resuscitation
by inserting an urinary catheter and monitoring
urine output (UOP) for amount and color, using these
guidelines:
– Adults UOP goal is 30 cc/hour.
– Pediatric UOP goal is 1 cc/kg/hour.
– Electrical injuries with myobloginuria UOP goal
is 75-100 cc/hour.
n Electrical and inhalation injuries may require
additional fluid during resuscitation.
n Elevate the head of the bed 30 degrees.
n Elevate affected extremities.
n Administer a tetanus prophylaxis.
Wound Care
Initially, the burn must be cooled with cool water, not cold
and not ice water. Wet dressings put in place in the prehospital setting must be removed and replaced with sterile,
dry dressings if more than 20 percent of the patient’s TBSA
is affected. Note that wound care is a low priority in the
initial care of a severely burned patient unless covering of
the burn with sterile, dry dressing reduces the pain and
increases the comfort level of the burn injured patient. It
should be noted that wound care should not be attempted
until well after the patient’s airway, breathing and
circulatory status have been addressed.
Follow these general guidelines but always ask the
receiving burn center for its preferences prior to initiation
of wound care:
1. If more than 10 percent of the patient’s TBSA is affected,
cover with a clean, dry sheet or dressings.
2. If more than 20 percent of the patient’s TBSA is injured,
cover with a clean dry sheet or dressings, and remember
to keep the patient warm with blankets or by increasing
the room temperature to 90 degrees.
3. If less than 10 percent of the patient’s TBSA is affected, saline moistened sterile dressings may be applied.
Pain and Anxiety Management
Pain from burns can be excruciating. Covering
the burns, warming the patient, elevating
burned extremities and pharmacological pain
control should be considered.
Anxiety is different from pain and may be
controlled with benzodiazepines.
Remember, the body surface area has been
damaged. Intramuscular and subcutaneous
routes should not be used due to fluid volume
changes and unpredictable blood flow/
absorption. Tetanus is the only medication
given intramuscularly in burn patients.
Intravenous pain medication should be
Third-Degree Burn
10
measured and adjusted to provide relief to the patient,
although careful monitoring of the patient’s respiratory
status is required.
Burn Center Referral Criteria
Does the patient meet the criteria for injuries requiring
referral to a designated burn unit? A clear answer should be
given in the pre-hospital setting, and the assessment must
be performed by the referring physician or the transporting
physician. Depending on the patient’s location, proximity
to a burn unit and capacity of the burn unit to accept a
patient transfer, initial treatment should be initiated in the
emergency room until transport to the burn unit takes
place. A burn center may treat adults, children or both.
Third-Degree Burn
Patients with the following burn injuries should be
referred to a burn center based on the following criteria
excerpted from the American Burn Association’s website
at www.ameriburn.org.
n Partial thickness burns greater than 10 percent of the
patient’s TBSA.
n Burns that involve the face, hands, feet, genitalia,
perineum or major joints.
n Third-degree burns in any age group.
n Electrical burns, including lightning injury.
n Chemical burns.
n Inhalation injury.
n Burn injury in patients with pre-existing medical
disorders that could complicate management, prolong
recovery or affect mortality.
n Any patient with burns and concomitant trauma (such
as fractures) in which the burn injury poses the greatest
risk of morbidity or mortality. In such cases, if the
trauma poses the greater immediate risk, the patient
initially may be stabilized in a trauma center before
being transferred to a burn unit. Physician judgment will
be necessary in such situations and should be in concert
with the regional medical control plan and triage
protocols.
n n Burned children in hospitals without qualified
personnel or equipment for the care of children.
Burn injury in patients who will require special social,
emotional or rehabilitative intervention.
Psychosocial and Spiritual Support
Psychological distress occurs in most survivors of severe
burn injuries. Although the hospital may be limited in
providing professional support due to the short time the
patient remains in the emergency center, the caregiver
should remain aware of the patient’s psychosocial status
and provide support as indicated. While each individual
experiences psychological distress differently, people with
burn injuries may report:
n Feeling sad, anxious or irritable,
n Feeling helpless,
n Feeling hopeless,
n Feeling alone,
n Being concerned about potential changes in lifestyle,
appearance, physical limitations, etc., and
n Feeling sad or angry about the loss of property, loved
ones or pets.
11
Examples of Fluid Resuscitation and
Wound Care Protocols
Fluid resuscitation recommendations vary in verified burn centers in Texas. Facilities in different geographic locations in
Texas should follow the recommendations of their regional tertiary burn center.
Timothy J. Harnar Burn Center –
UMC Health System, Lubbock
Parkland Burn Center, Dallas
Hotline: 214/590-6690
Hotline: 800/345-9911
Fluid Resuscitation
Follow Advanced Burn Life Support recommendations.
If available, titrate fluid up or down in response to
urinary output via foley catheter.
Pediatric:
3 ml LR x patient’s body weight in kg x % TBSA secondand third-degree burns
Pediatric High Voltage Electric Burns:
4ml LR x patient’s body weight in kg x % TBSA secondand third-degree burns
Adult:
For thermal and chemical burns: 2 ml LR x patient’s
body weight in kg x % TBSA second-and third-degree
burns
Adult High Voltage Electrical Burns:
4ml LR x patient’s body weight in kg x % TBSA secondand third-degree burns
Geriatrics:
2 ml LR x patient’s body weight in kg x % TBSA secondand third-degree burns
Fluid Resuscitation
Follow Advanced Burn Life Support recommendations.
Pediatric:
3 ml LR x patient’s body weight in kg x % TBSA second- and
third-degree burns
Pediatric High Voltage Electric Burns:
4ml LR x patient’s body weight in kg x % TBSA second- and
third-degree burns
Adult:
For thermal and chemical burns: 2 ml LR x patient’s body
weight in kg x % TBSA second- and third- degree burns
Adult High Voltage Electrical Burns:
4ml LR x patient’s body weight in kg x % TBSA second- and
third-degree burns
Geriatrics:
Same as adults.
Wound Care
For all burns regardless of size – cover the burn injury with
a clean dry sheet or dressing.
12
Burn Unit – San Antonio Medical Center
UTMB Galveston Blocker Burn Unit
Hotline: 210/916-4141
Hotline: 800/962-3648
Fluid Resuscitation
Per 2010 Advanced Burn Life Support guidelines for
burns greater than 20 percent of the patient’s TBSA.
Fluid resuscitation
Pediatric:
2-4 ml per kg x TBSA with UOP goal of 0.5 ml – 1 ml
per kg/hour
Pediatric High Voltage Electric Burns:
2-4 ml per kg x TBSA with UOP goal of 0.5 ml – 1 ml
per kg/hour
Pediatric prehospital:
> 5 years old: 125 cc/hour LR
6-13 years old: 250 cc/hour LR
14 years and older (adult rate): 500 cc/hour LR
If patient is less than 10 kg, use D5LR
Adult:
2-4 ml per kg x TBSA with UOP goal of 30 ml/hour
Pediatric High Voltage Electric Burns:
Consult Shriners Hospital at 409/770-6773
Adult High Voltage Electrical Burns:
2-4 ml per kg x TBSA with UOP goal of 75-100 cc/hour;
if myoglobinuria present, may require additional fluid
during resuscitation.
Adult prehospital:
500 cc/hour of LR
Adult High Voltage Electrical Burns prehospital:
500 cc/hour of LR
Geriatrics:
2-4 ml per kg x TBSA with UOP goal of 30 ml/hour
Geriatrics: prehospital:
500 cc/hour of LR
Wound Care
1. No wound care if the patient is being transferred to a
burn center within 24 hours. If unable to transfer, then
contact local burn center.
2. If less than 10 percent of the patient’s TBSA, salinemoistened sterile dressings may be applied.
3. If more than 10 percent of the patient’s TBSA, cover
with clean dry sheet.
4. If greater than 20 percent of the patient’s TBSA, cover
with a clean dry sheet and remember to keep the
patient warm with blankets or by increasing the room
temperature to 90 degrees.
Wound Care
Cover with clean dry sheet or dressings. Keep warm.
13
Forms and Tools for Documentation
There are many accessible resources for forms and tools
that a hospital may use for documentation models. The
following information is provided as a guideline and should
be considered recommendations only.
Assessment Charts
The Rule of Nines is used to assess the percentage of burn
injuries and is used to help guide treatment decisions
including fluid resuscitation and becomes part of the
guidelines to determine transfer to a burn unit. Having a
Rule of Nines chart is recommended; see Appendix A. The
Rule of Nines is recommended for initial burn resuscitation
prior to burn center transfer. The Lund-Browder chart is
recommended after initial burn care and debridement.
Burn Care Sheet
Use a Burn Care Sheet, a tool to travel with the patient
for the first 24 hours of care. An example is provided as
Appendix B. Hospitals also may use one developed by their
facility’s team or their RAC.
Performance Improvement Patient Safety (PIPS)
As with trauma, the care of burn patients should receive
a very robust review of standards, protocol utilization,
documentation, fluid resuscitation and outcomes. The burn
review within PIPS must include additional quality filters to
ensure the standard of care is met.
n Resuscitation Phase:
n All burn patients with second- or third-degree burns
had a burn flow sheet.
n All burn patients meeting criteria had a definitive airway
established.
n All burn patients with TBSA of 20 percent or more had
nasogastric or progastric tube placed.
n Wound care provided as per recommendations of
receiving burn center.
n Warming efforts documented.
n Serial vitals, including a temperature, documented.
n Volume of resuscitation fluid required for optimal
patient response during the first 24 hours was
appropriate based on:
1. TBSA percentage calculation,
2. Fluid resuscitation formula appropriately executed and documented including bolus and maintenance fluid resuscitation, 3. Resuscitation success/failure monitored based on hemodynamic status and urinary output, and
4. Intake and output documented on 24-hour burn flow sheet, which traveled with the patient.
Additional Considerations:
Total length of hospital stay is important for several
reasons, including burn bed availability, transfer issues
and recognition that in some situations non-burn
centers may have to maintain this patient.
n Unanticipated readmissions.
n Mortality.
n Performance Measures by Phases of Care
Prehospital Phase:
n Definitive airway management during resuscitative
phase provided
n IV started, intake and output monitored
n Burn care provided
n Scene time, transport time and destination appropriate
Documentation of fluid volume should start at point of
injury to reinforce the 24-hour flow sheet.
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Education Recommendations
These resources may assist the hospital in developing specific policies and procedures for treating patients with burn
injuries. In addition, specific educational programs – both online and in-person – may help clinicians treating burn
patients improve their practice.
Burn Care Resource Websites
American Burn Association
http://www.ameriburn.org/ablsgeneralinfo.php
Educational Programming
The American Burn Association offers three Advanced
Burn Life Support program options:
Center for Disease Control & Prevention
http://www.cdc.gov/masstrauma/factsheets/public/burns.pdf
ABLS Provider Course Live© – A two-day in-person
hands-on course designed to provide the “how-to”
of emergency care of the burn patient; registration is
available online.
http://www.cdc.gov/mmwr/PDF/wk/mm4237.pdf
(occupational burns among restaurant workers)
ABLS Now© – Convenient online course providing burn
injury training and education for busy first responders
and health care providers.
International Society for Burn Injuries
http://www.worldburn.org/
ABLS Handbook© – The go-to reference guide for
comprehensive information on immediate care through
the first 24 hours post burn injury.
National Rehabilitation Information Center
http://www.naric.com
Public Domain Files/Resources List
http://docsfiles.com/pdf_burns_care_resources.html
Most burn centers offer outreach education. Contact
your local burn center regarding its educational
programs.
Wound Care Advisor
http://woundcareadvisor.com/resources/
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Appendices
Appendix A: Rule of Nines – Diagram for use in documentation.
Appendix B: 24-Hour Burn Care Sheet – Complete documentation that should travel with the patient.
16
infant
Posterior
Anterior
Palmar
Method
Patient’s palm,
including fingers.
Note: The American Burn Association recently has approved the Rule of
10, and once it is implemented, will be incorporated in this document.
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> 15% Trauma
Burn
Surface
Area Burn Resuscitation
> 15%
TBSA
BURN RESUSCITATION
FLOWSHEET Flowsheet
Date
Name
Date & Time of Injury
Provider Initial
Initials & hour
Care
from
Team
burn
Time
1st
2nd
3rd
4th
5th
6th
7th
8th
Total Fluids:
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
Total Fluids:
REFERRING FACILITY
Identify #
DOB or MRN
Crystalloid Colloid
Estimated fluid vol. pt should receive
Pre2-4 ml x a (kg) x b (TBSA) = TOTAL
Burn
ml/24 hrs (___)
est.wt % TBSA
24 hr total ÷ 2 =
TOTAL ml (___) for 1st 8 hrs
(kg) (a) (b)
Burn Center Name:
Total
UOP
Base
Deficit
BP
Pressors
Initials:______ Name/Title:_______________________________________ Date:_____________
Initials:______ Name/Title:_______________________________________ Date:_____________
Initials:______ Name/Title:_______________________________________ Date:_____________
Regardless of which ever formula or solution type utilized for resuscitation - assessment of fluid resuscitation
UOP must be monitored (Adult UOP goal: 30ml/hr and Pedi UOP goal is 0.5ml - 1ml/kg
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> 15 % TBSA BURN REUSCITATION FLOWSHEET
Date
1
REFERRING FACILITY
2
Estimated fluid vol. pt should receive
(1) Date: Today's date
(2) Referring Facility: There this form
Pre2-4 ml x a (kg) x b (TBSA) = TOTAL
was
initiated
Burn
ml/24 hrs (___)
(3)
Name:
Patient's Name
est.wt
Identy#
24 hr total ÷ 2 =
(kg)
% TBSA
Name
DOB or MRN
TOTAL ml (___) for 1st 8 hrs
(4) Identity/DOB/MRN - self
explanatory
5
7
6
3
4
(5) Weight in Kg: Estimated weight
Date & Time of Injury
8
Burn Center Name:
PREBURN "dry weight"
(6)% TBSA: area burned
9
10
16
11
12
13
14
15
17
18
(7) Calculation of individualized RAC
Burn
Center Policy: Total fluids
Initial
hour
Provider
calculated for the 1st 24 hrs and the
from
Base
Initials &
1st 8 hrs
Deficit BP Pressors
Care Team burn Time Crystalloid Colloid Total
UOP
(8) Date & Time of Injury: Date &
1st
time of burn. Not the time pt arrived
2nd
to your facility
3rd
(9) Provider Initials & Care Team:
Initial of provider and name of Care
4th
Team i.e., AirLIFE
5th
(10) Initial hour from burn: 1st hour
6th
of post-burn i.e., Pt burned 2 hrs
7th
prior arrival, facility will start
8th
charting for pt on the 3rd hour.
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Total Fluids:
(11) Local Time: time being used by
9th
recorder
10th
(12) Crystalloid (ml): total of
11th
crystalloid volume give over last hour
(13) Colloid (ml): total of colloid
12th
volume
given over the last hour i.e.,
13th
Albumin,
blood
14th
(14) Total: Total volume (crystalloid
15th
+ colloids) for that hour
16th
(15) UOP: Urine output for last for
17th
last hour
18th
(16) Base Deficit: self explanatory
19th
(17) BP: Systolic BP/Diastolic BP
20th
(18) Pressors: Vasopressin, Levophed
21st
with rate and dose
(19) Total Fluids: 8 hour total of
22nd
Crystalloid and Colloid fluid. For Pedi
23rd
- resuscitation fluids does not
24th
replace maintanence fluid
20
Total Fluids:
requirements for pediatric patients
21
(20) Total Fluids: 24 hour total of
Initials:______ Name/Title:______________________________ Date:_____________
Crystalloid and Colloid Fluid
Initials:______ Name/Title:______________________________ Date:_____________
(21) Initials/Name & Title/Date:
Initials:______ Name/Title:______________________________ Date:_____________
Legible initals and signature of
provider documenting this flowsheet
19
Section 8
References
Advanced Burn Life Support.
Parkland Regional Burn Center (2013). Burn Policy
Level 3 and Level 4.
Advanced Trauma Life Support.
Alfred Health, Burns Management Guidelines,
http://www.vicburns.org.au/about.html
American Burn Association Provider Manual 2011,
http://www.ameriburn.org/verification_guidelines.php
American College of Surgeons, Committee on Trauma,
Resources for Optimal Care of the Injured Patient (2006).
Chung, K.K.; Salinas, J.; Renz, E.M.; Alvarado, R.A.; King,
B.T.; Barillo, D.J.; Cancio, L.C.; Wolf, S.E.; Blackbourne, L.H.,
“Simple derivation of the initial fluid rate for resuscitation of
severely burned adult combat casualties: in silico validation
of the rule of 10,” Journal of Trauma, 2010; 69(1): S49-54.
Emergency War Surgery Handbook, Chapter 28
Ennis, J.L.; Chung, K.K.; Renz, E.M.; Barillo, D.J.; Albrecht,
M.C.; Jones, J.A.; Blackbourne, L.H.; Cancio, L.C.; Eastridge,
B.J.; Flaherty, S.F.; Dorlac, W.C.; Kelleher, K.S.; Wade, C.E.;
Wolf, S.E.; Jenkins, D.H.; Holcomb, J.B.; “Joint Theater Trauma
System implementation of burn resuscitation guidelines
improves outcomes in severely burned military casualties,”
Journal of Trauma, 2008; 64(2): S146-51; discussion 151-2.
First Aid for Burns, Medicine.Net,
http://www.medicinenet.com/burns/article.htm
San Antonio Medical Center Fluid Resuscitation and
Wound Care Protocols.
Sharma, R.K.; Parashar, A.; “Special considerations in
paediatric burn patients,” Indian Journal of Plastic Surgery,
2010 September: 43 (Suppl): pages 43-50. Retrieved from:
www.ijps.org
Timothy J. Harnar Burn Center, University Medical Center
Health System, Lubbock, Fluid Resuscitation and Wound
Care Protocols.
Trauma Nursing Core Course Provider Manual, Sixth
Edition.
University of Texas Medical Branch Galveston Blocker
Burn Unit Fluid Resuscitation and Wound Care Protocols.
U.S. Institute of Surgical Research – Clinical Practice
Guidelines Burn Care 2013,
http://www.usaisr.amedd.army.mil
Ziyad Alharbi, Andrzej Piatkowski, Rolf Dembinski, Sven
Reckort, Gerrit Grieb, Jens Kauczok, Norbert Pallua;
“Treatment of burns in the first 24 hours: simple and
practical guide by answering 10 questions in a step-bystep form,” World Journal of Emergency Surgery, 2012, 7:13.
Retrieved from:
http://www.wjes.org/content/pdf/1749-7922-7-13.pdf
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